Safe to Sleep in Tennessee: A Statewide Quality Improvement Initiative

Am J Perinatol. 2024 May;41(S 01):e1747-e1755. doi: 10.1055/s-0043-1768705. Epub 2023 May 11.


Objective: Sleep-related deaths were the fourth leading cause of infant death in Tennessee between 2014 and 2018. In response, the Tennessee Initiative for Perinatal Quality Care developed a statewide quality improvement project, which focused on the demonstration and enforcement of a safe sleep environment in participating birthing hospitals to help families learn and practice the same at home. The project's aim was to improve the percent of infants audited for safe sleep practices (0-12 mo of age, cared for in participating newborn nurseries or neonatal intensive care units) that were compliant with the practices recommended by the 2016 American Academy of Pediatrics (AAP) Task Force on Sudden Infant Death Syndrome.

Study design: Participating teams were required to develop and implement safe sleep policies in compliance with the AAP recommendations, provide safe sleep education to staff and families, and complete monthly safe sleep audits. A tool was provided to assess whether each audited infant was compliant with safe sleep recommendations and any reason(s) the infant was not compliant. Teams met virtually for monthly huddles and semiannual learning sessions to discuss the development and testing of change ideas.

Results: The project teams were able to improve the percent of infants audited that were compliant with safe sleep recommendations by 22% over the course of the project. Audits revealed the main reasons for noncompliance were additional objects in the crib (49%, 329/671), unsafe bedding (27%, 181/671), and head of bed elevation (24%, 164/671).

Conclusion: This project demonstrates the positive impact that a statewide quality improvement initiative can have on identifying and addressing barriers, sharing resources and education, and monitoring local and statewide data, which led to increased compliance with safe sleep recommendations in the hospital. Safe sleep education and monitoring should be ongoing as new parents and staff always need to be educated on safe sleep principles.

Key points: · In 2020, 25% of all infant deaths in Tennessee were due to an unsafe sleep environment.. · Sleep-related deaths in infants are frequently preventable.. · State quality improvement projects are effective in increasing safe sleep compliance.. · State perinatal quality collaboratives can partner with their State Department of Health, local hospitals, and providers, to increase awareness, educate parents, and model a safe sleep environment..

MeSH terms

  • Guideline Adherence
  • Humans
  • Infant
  • Infant Care / standards
  • Infant, Newborn
  • Intensive Care Units, Neonatal / standards
  • Quality Improvement*
  • Sleep*
  • Sudden Infant Death* / prevention & control
  • Tennessee